NATIONAL MARITIME CENTER DETACHMENTS - Sea … OS CG-PKT.pdf · NATIONAL MARITIME CENTER DETACHMENTS KNOWN AS REGIONAL EXAMINATION CENTERS (RECs) (As listed on USCG web site 06/17/15)

NATIONAL MARITIME CENTER DETACHMENTS KNOWN AS REGIONAL EXAMINATION CENTERS (RECs)

(As listed on USCG web site 06/17/15) ALASKA, Anchorage U.S. Coast Guard, Marine Safety Office (REC),

222 W. 7th Ave., Box 55, Room 156, Anchorage AK 99515

ALASKA, Juneau U.S. Coast Guard, Marine Safety Office (REC), (907) 463-2458 9105 Mendenhall Mall Rd. Suite 170, Juneau AK 99801 CALIFORNIA, Oakland U.S. Coast Guard, Marine Safety Office (REC), Federal Bldg,

North Tower, 1301 Clay St. Rm. 180N, Oakland CA 94612-5200

CALIFORNIA, Long Beach U.S. Coast Guard, Marine Safety Office (REC), 501 W. Ocean Blvd, Ste 6200, Long Beach CA 90802 FLORIDA, Miami U.S. Coast Guard, Marine Safety Office (REC), (305) 536-6548 6th Floor, Federal Building, 51 SW First Ave., Miami FL 33130-1608 HAWAII, Honolulu U.S. Coast Guard, Regional Exam Center ( REC), (808) 522-8264 Honolulu Harbor Pier 4 433 Ala Moana Blvd. Honolulu HI 96813 LOUISIANA, New Orleans U.S. Coast Guard, Regional Exam Center (REC) (985) 624-5700 4250 Hwy 22, Suite F, Mandeville LA 70471 MARYLAND, Baltimore U.S. Coast Guard, Marine Safety Office (REC), US Custom

House, Rm 420, 40 S. Gay St., Baltimore MD 21202-4022 MASSACHUSETTS, Boston U.S. Coast Guard, Marine Safety Office (REC), (617) 223-3040 455 Commercial St., Boston MA 02109-1045 MISSOURI, St. Louis U.S. Coast Guard, Marine Safety Office (REC), (314) 539-3091 Suite 7.105, 1222 Spruce St., St. Louis MO 63103-2846 NEW YORK, New York U.S. Coast Guard Activities New York, (REC), Battery Park Bldg., 1 South St., New York NY 10004-1466 OHIO, Toledo U.S. Coast Guard, Marine Safety Office (REC), 420 Madison

Ave., Suite 700, Toledo OH 43604-1209 OREGON, Portland U.S. Coast Guard, Marine Safety Office (REC), (503) 240-9346 911 NE 11

th Ave, Rm 637, Portland OR 97232

S. CAROLINA, Charleston U.S. Coast Guard, Marine Safety Office (REC), (843) 720-3250 196 Tradd St., Charleston SC 29401-1899 TENNESSEE, Memphis U.S. Coast Guard, Marine Safety Office (REC), (901) 544-3297 200 Jefferson Ave., Suite 1301, Memphis TN 38103-2300 TEXAS, Houston U.S. Coast Guard, Marine Inspection Office (REC), (713) 948-3350 8876 Gulf Freeway, Suite 200, Houston TX 77017-6595 WASHINGTON, Seattle U.S. Coast Guard, Marine Inspection Office (REC), (206) 220-7327 915 Second Ave., Rm. 194, Seattle WA 98174-1067 The Coast Guard has requested that all phone calls to the RECs be made through the National Maritime Center at (888) 427-5662. LIST.doc (0916)

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CG-719B (01/14) Page 1 of 6

DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040

U.S. Coast Guard Exp. Date: 01/31/2016

APPLICATION FOR MERCHANT MARINER CREDENTIAL (MMC)

------ Instructions ------

Who must submit this form?

Applicants seeking a Merchant Mariner Credential (MMC), whether original, renewal, duplicate, raise of grade, or a new endorsement on a previously issued

MMC.

Section I: Personal Data

I.1 Legal Name - Enter complete legal name. Include any aliases you have used and your maiden or prior name(s).

I.2a Social Security Number - If you are applying for an original credential, enter your SSN.

I.2b Reference Number - If you have been credentialed by the Coast Guard in the past, enter your reference number.

I.2c Alien Registration Number - If you are a legal alien, also enter your alien registration number (ARN).

I.3 Date of Birth - If applicant is under 18 years of age, notarized statement from legal guardian is required. Attach a notarized statement, signed by a

parent or legal guardian, authorizing the Coast Guard to issue a credential.

I.4 Citizen - If not a U.S. citizen, please indicate country of nationality.

I.5a-c Place of Birth - City, State, Country. If born outside the United States, leave State blank.

Section I: Mariner Contact Information (Please indicate best method(s) of contact by checking the appropriate

box(es).) (If NMC is unable to contact you, it could cause delays in processing your application.)

Next of Kin/Emergency Contact: (Check the box for preferred contact method)

Remove Instructions before submitting Application

I.6a Home Address - Principle place of residence. PO Box is NOT acceptable.

I.6b Delivery/Mailing Address - The address to which you want all correspondence and issued credentials sent. If blank, correspondence and

credentials will be sent to the Home Address.

I.6c Primary Phone Number - Provide a primary phone number.

I.6d Alternate Phone Number - Provide an alternate phone number if available.

I.6e E-mail Address - The NMC may attempt to contact you via e-mail. You will receive automated e-mail updates regarding the status of your

application.

I.6f Other - Please provide additional means of communicating with you (satellite phone, work phone, etc.) if available.

Section II: Requested Coast Guard Credential(s)

Instruction: See Figure 1 (additional requirements) on the last page of these instructions for further guidance

regarding information you may be required to submit with the application. Attach additional sheets if you cannot fit

all information in a block.

I.7a Next of Kin/Emergency Contact - Name & Mailing Address, City, State, Zip Code

I.7b Relationship - Provide relationship status to next of kin listed on application. (i.e. Mother, Father, Spouse)

I.7c Primary Phone Number - Phone number to contact the person listed in the event of an emergency.

I.7d Alternate Phone Number - Provide a cellular phone number, if available.

I.7e E-mail Address - Provide an e-mail address for Next of Kin listed.

Transaction Type - Place a check in the box for each transaction type that applies.

Original - An applicant must apply for an original MMC if they have never held any Coast Guard issued credential or if the first credential issued to applicant

after their previous credential was revoked pursuant to 46 CFR Part 10. Complete the application and ensure all mandatory documents are contained with

application.

Renewal - A credential may be renewed at any time during its validity and for one year after expiration; you must be qualified to renew all Domestic /STCW

Officer and Rating endorsements to receive a new five year expiration date. An MMC renewal-only transaction will automatically be issued with a date that

coincides with the expiration date of your previous credential or a date that is 8-months from the time the Coast Guard accepted your application, whichever

is sooner. Page 4, Section II of this form provides you the opportunity to decline this post-dating feature and receive your MMC immediately.

Duplicate - In the event of a lost credential, a statement describing the circumstances of the loss must be submitted with the application. The duplicate will

have the same authority, wording and expiration date as the lost credential. If a person loses a credential by shipwreck or other casualty that causes damage

to a ship, a duplicate will be issued free of charge as per 46 CFR Part 10. If a person loses a credential by other means and applies for a duplicate, the

appropriate fee set out in 46 CFR Part 10 must be paid. No application from an alien for a duplicate credential will be accepted unless the alien complies with

the requirements of 46 CFR.

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CG-719B (01/14) Page 2 of 6

Section III: Safety and Suitability

III. 1 TWIC Information: Unless specifically exempted, the Coast Guard must have evidence that you hold a valid TWIC or, for original applicants, that

you have enrolled for a TWIC and are awaiting the results. With the exception of applicants for Documents of Continuity, no mariner credential will

be issued until the Coast Guard receives information from the TSA that you are currently or have previously been approved to hold a TWIC.

Exemptions from holding a valid TWIC:

a. Mariners applying for a Document of Continuity are not required to enroll for a TWIC.

b. Mariners who are inactive or not operating under the authority of their credential. This exemption will cease to exist if the mariner subsequently

chooses to work under the authority of their credential.

c. Mariners who serve on vessels that are not required to have a vessel security plan. These vessels include:

i. Uninspected passenger vessels of less than 100 gross register tons (GRT); and

ii. Vessels inspected under subchapter T of Title 46 Code of Federal Regulations, except those on international voyages; and

iii. Towing vessels not involved in towing barges inspected under 46 CFR subchapters D, I or O; and

iv. Towing vessels involved in fleeting, docking, or ship assist as excepted in Title 33 CFR, Section 104.105(a)(11).

This exemption will cease to exist if the mariner subsequently chooses to work under the authority of their credential on vessels not specifically

exempted

III. 2a-e Convictions and Drug Use

Has applicant used dangerous drugs, including marijuana within the past 10 years? Check YES or No. Applicant must provide evidence of having

passed a chemical test for dangerous drugs or qualify for an exemption from testing as per 46 CFR. Original applicants are required to list all

convictions. Conviction means that the applicant for a merchant mariner credential has been found guilty, by judgment or plea by a court of record of

the United States, the District of Columbia, any State, territory, or possession of the United States, a foreign country, or a military court, of a criminal

felony or misdemeanor or of an offense described in section 205 of the National Driver Register Act of 1982, as amended (49 U.S.C. 30304). If an

applicant pleads guilty or no contest, is granted deferred adjudication, or is required by the court to attend classes, make contributions of time or

money, receive treatment, submit to any manner of probation or supervision, or forgo appeal of a trial court's conviction, then the Coast Guard will

consider the applicant to have received a conviction. A later expungement of the conviction will not negate a conviction unless the Coast Guard is

satisfied that the expungement is based upon a showing that the court's earlier conviction was in error. If you are unsure what you previously reported,

you are encouraged to provide a complete list of all convictions. Failure to report convictions will delay your credential and may result in denial.

III.3 National Driver Registry (NDR): No MMC will be issued as an original or reissued with a new expiration date, and no new officer endorsement

will be issued, unless the applicant consents to an NDR check as per 46 USC 7505.

Raise of Grade or New Endorsement - Is defined as an increase in the level of authority and responsibility associated with an officer or rating endorsement.

You must first hold an MMC before an endorsement is issued for a Raise of Grade and/or Increase in Scope (e.g. Raise of Grade of 3rd mate to 2nd mate will

not change the expiration date unless specifically requested and renewal requirements are met for all other endorsements on MMC).

Increase in Scope - Increase in scope may include a change in horsepower, propulsion or tonnage limitations, or geographic route restrictions. You must first

hold an MMC before an endorsement is issued for a Raise of Grade and/or Increase in Scope. Endorsements maintain the same expiration date as the

credential being endorsed.

Document of Continuity - Documents of continuity do not expire, do not require medical or security evaluations, and do not require fees. They are a record

of competencies previously held and do not authorize the holder to sail in any capacity listed thereon.

Description of MMC or Endorsement Desired - All Mariners will receive a single Merchant Mariner Credential. Describe all capacities and limitations both

domestic and STCW including tonnage, waters, propulsion mode, horsepower, ratings (Ordinary Seaman, Able Seaman, QMED-Oiler, etc.), purser, doctor,

radio operator, continuity, etc.

NOTE: Entry Level Ratings - There are no professional requirements needed when applying for entry level credential. Ratings may include Ordinary

Seaman, Wiper, and/or Stewards Department / Stewards Department (Food Handler - F.H.). Per 46 CFR Part 10, applicants requesting Stewards Department

(F.H.) will be required to submit a statement attesting applicant is free from communicable disease

Section IV: Mariner's Consent/Certification

IV.1 Mariner Outreach System (MOS): This is an optional program. Applicant will need to select whether Yes, they would like to participate, or No, they

do not wish to participate in the Mariner Outreach System, by selecting either of the check boxes.

IV.2 Continuity: Credentials issued for continuity purposes are not valid for use.

IV.3 Consent: Applicants under the age of 18 must attach a notarized statement of parental/guardian consent.

IV.4 Third Party Release: If you want the NMC to be able to discuss, release, or receive information/documents regarding your credential application

with a third party (spouse, employer, school, union, etc.) you must provide specific guidance to the NMC regarding what issues we may discuss and

with whom. You may allow release of all information to certain individuals or entities. If you limit the release of certain information you must be

specific by making a selection on the application or by attaching additional documentation. For each selection made, ensure the Name of the

Organization or Third Party, Organization Point of Contact (if applicable), Address and Phone Number is completed. If you wish to provide multiple

Third Party Releases, attach additional pages as needed. A sample may be found on the NMC website: http://www.uscg.mil/nmc/.

IV.5 Certification: Applicant certifies that the information provided is true and correct. Every person who applies for an original MMC must first take an

oath. The applicant must sign and date the application stating they have taken the oath. Failure to sign will result in the application being returned.

Per 46 CFR 10.225(c), an oath may by administered by any Coast Guard designated individual or any person legally permitted to administer oaths

in the jurisdiction where the person taking the oath resides.

IV.6 Signature and Date: Failure to sign and date the application will result in the application being returned.

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CG-719B (01/14) Page 3 of 6

Figure 1:

Attachment to Include: Endorsement Categories and Transaction Types

The following attachments are

required for transactions to the

right.

Original Entry

Level Rating

Endorsement

Qualified

Original Rating

Endorsement

Original Officer

Endorsement Renewal Duplicate

Raise of

Grade/New

Endorsement

USRP

Endorsement

(see note)

Doc. Of

Continuity

Certificate of

Registry

(Original)

Statement of Loss (Duplicate)

46 CFR 10.229(a)

User Fees: Copy of Receipt

from www.pay.gov

46 CFR 10.219(a)

Oath (For original only)

46 CFR 10.225(c)

Complete Physical CG 719K

(Last 12 Months)

46 CFR 10.215

Complete Physical CG 719K

(Approved Last 36 Months)

46 CFR 10.215

Complete Physical CG 719K/E

(Last 12 Months, Entry Level

Applicants Only)

46 CFR 10.215

Drug Screen

46 CFR 10.225(b)(5)

Copy of All Current

Credential(s)

Sea Service

46 CFR Parts 10, 11, 12 and 13 * **

Notarized Statement from Legal

Guardian for Applicants

< 18 YOA

46 CFR 11.201(e)

* A pilot association letter of attestation will be accepted for First Class Pilots.

** Sea Service minimum for USRP Endorsement: 24 months licensed service aboard vessel of 4,000 GRT (incl waters navigated: oceans; coastal; inland lakes,

bays and sounds; rivers; and Great Lakes) Include Vessel name, Official Number/State Registration Number, GRT, Waters Navigated, Licensed Position, Dates

Served on Vessel, and Number of Total days served.

NOTE: When ONLY applying for an original or renewal of a USRP endorsement, scan completed application along with any additional supporting

documentation and email to [email protected] or send via regular mail to:

Commandant (CG-WWM-2)

ATTN: Great Lakes Pilotage Division

U.S. Coast Guard: Stop 7509

2703 Martin Luther King Jr. Ave., SE

Washington, DC 20593-7509

Any questions or for assistance, contact NMC Customer Service Center: 1-888-IASKNMC

(1-888-427-5662) or http://www.uscg.mil/nmc/contact_iasknmc.asp

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✔ ✔ ✔ ✔ ✔ ✔ ✔

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CG-719B (01/14) Page 4 of 6




Section I: Personal Data

1. Legal Name: Last First Name Middle Name Suffix (Jr., Sr., III)

2b. Reference Number (if applicable) 3. Date of Birth (MM/DD/YYYY)

Mariner Information (Please indicate best method(s) of contact by checking the appropriate box(es)).

Next of Kin/Emergency Contact (Please indicate best method(s) of contact by checking the appropriate box(es).) (Optional)

Zip CodeStateCity

Street Address

6a. Home Address (PO Box NOT acceptable)

6b. Delivery/Mailing Address, if different (PO Box acceptable)

Zip CodeStateCity

6c. Primary Phone Number

6d. Alternate Phone Number

6e. E-mail Address

6f. Other

Section II: Requested Coast Guard Credential(s)

Description of Endorsement(s) Desired: Include all appropriate information - Officer (i.e. Deck - Master/Mate/Propulsion/Tonnage/Route/United States

Registered Pilot OR Engineer Grade - 3rd AE; DDE/Propulsion/Horsepower) Ratings (i.e.: Able Seaman, Tankerman, QMED, Lifeboatman) (Please Print)

Alias(es) or Maiden Name(s) if applicable

2a. SSN (for Original only) 2c. Alien Registration Number (ARN) (if applicable)

4. Citizenship/Nationality 5a. Place of Birth (City) 5b. State 5c.Country 5d. Color of Eyes 5e. Color of Hair

Street Address

7b. Relationship (Optional)

7c. Primary Phone Number (Optional)

7d. Alternate Phone Number (Optional)

7e. E-mail Address (Optional)Zip CodeStateCity

Street Address

7a. Name & Mailing Address, City, State, Zip Code

Same address as above

Credential or Endorsement Type(s) Requested:

EndorsementTransaction Type (Check all that apply: See instructions for definitions and additional requirements for the transaction below)

CategoryOriginal Renewal Duplicate

Raise of Grade, New Endorsement

or Increase in ScopeCertificate of Registry Document of Continuity

Officer

Qualified Rating

Entry Level

STCW

FOR RENEWAL TRANSACTIONS ONLY: I request to have my merchant mariner credential (MMC) issued immediately and decline having its issuance

coincide with my previous credentials expiration date.

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CG-719B (01/14) Page 5 of 6

Zip CodeStateCity

Street Address

Section III: Safety and Suitability

Phone Number

Organization Point of Contact (if applicable)

Name of Organization or Third Party

4a. Safety and Suitability

4b. Professional qualifications, certification records, or Sea Service

4c. Merchant Mariner Credential Delivery

4d. Act on my behalf in all matters pertaining to the processing of my

current USCG credential application.

4. Third Party (Optional)

* By checking the following boxes, I am authorizing release of information to the third party as indicated below. If a selection is made, please provide the

Name of the Organization or Third Party, Address, and Phone Number. Additional Third Party release information can be attached separately.

3. I am under 18 years of age and a notarized statement of parental/guardian consent is attached.

2. I understand that a Document of Continuity is not valid for use in accordance with 46 CFR 10.227 (e)(2)(ii) and aware of the requirements to obtain

an MMC.

Section IV: Mariner's Consent/Certification

1. Mariner Outreach System (MOS) (Optional): I consent to voluntary participation in the Mariner Outreach System to be used by the Maritime Administration

(MARAD) in the event of a national emergency or sealift crisis. In such an emergency, MARAD would disseminate my contact information to an appropriate

maritime employment office to determine my availability for possible employment on a sealift vessel. Once consent is given, it remains effective until revoked

either by subsequent application or by sending a signed notice or revocation to the U.S. Coast Guard National Maritime Center, 100 Forbes Dr., Martinsburg,

WV 25404. For more information on MOS, please visit https://mos.marad.dot.gov/.

3. National Driver Registry (NDR) (Mandatory for Original, Renewal, or new Officer Endorsement): I authorize the National Driver Registry to

furnish the U.S. Coast Guard (USCG) information pertaining to my driving record. This consent constitutes authorization for a single access to the

information contained in the NDR to verify information provided in this application. NOTE: Not required for Document of Continuity applicants.

I understand the USCG will make the information received from the NDR available to me for review and written comment prior to disapproving my

application or taking any action against my Merchant mariner's Credential. Authority: 46 U.S.C. 710(g), 46 U.S.C. 7302(c), and 46 U.S.C. 7505.




1. Transportation Worker's Identification Credential (TWIC) - I have previously enrolled for a TWIC with TSA and I am exempt from holding a valid TWIC

under Coast Guard Policy Letter 11-15. I understand that a name based safety and suitability check could significantly delay the processing of my

Merchant Mariner Credential Application.

a) Have you ever been a user of/or addicted to a dangerous drug, including marijuana, within the last 10 years? NoYes

b) Have you ever been convicted of violating a dangerous drug law of the United States, District of Columbia, or any state, or

territory of the United States?

c) Have you ever been convicted by any court-including military court - for an offence other than a minor traffic violation?

d) Have you ever been convicted of a traffic infraction arising in a connection with a fatal traffic accident, reckless driving or racing

on a highway or operating a motor vehicle while under the influence of, or impaired by, alcohol or a controlled substance?

e) Have you ever had your driver's license revoked or suspended for refusing to submit to an alcohol or drug test?

f) Have you had a drug test with a result other than negative within the last 10-years?

2. Convictions and Drug Use (NOT PREVIOUSLY DISCLOSED): If you answer Yes to ANY of the below questions complete the CG-719C or its equivalent for

each question marked “Yes”

No thanks, I do not wish to participate at this timeYes, I would like to participate

5. Certification

My signature below attests that:

• All information on this application is true and correct to the best of my knowledge.

• I understand an application determined to be fraudulent may result in the denial of my application for one year from the date of submission, even if the

fraudulent information was not by itself cause for denial or prosecution.

• If registered as a U.S. Registered Pilot, I will obey all application regulations of the Secretary of Homeland Security, the U.S. Coast Guard and of any

other Federal Agency; and that I will be continuously available for service when required on those waters of the Great Lakes for which registered.

• I consent to a check of the National Driver Registry related to my driving history, including motor vehicle convictions involving alcohol or controlled

substances; and any traffic violations in connection with a fatal traffic accident, reckless driving or racing.

• I understand that by checking boxes 4a - 4d in Section IV, I authorize release of information to the third party indicated until issuance of a MMC or until

Agency final action is made.

• I do solemnly swear or affirm that I will faithfully and honestly, according to my best skill and judgment, and without concealment and reservation, perform

all the duties required of me by the laws of the United States. I will faithfully and honestly carry out the lawful orders of my superior officers aboard a

vessel.

NoYes

NoYes

NoYes

NoYes

NoYes

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CG-719B (01/14) Page 6 of 6

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.

The United States Coast Guard estimates that the average burden for this report is 9 minutes. You may submit any comments concerning the accuracy of this

burden estimate or any suggestions for reducing the burden to: Commanding Officer, U.S. Coast Guard National Maritime Center, 100 Forbes Dr., Martinsburg,

WV 25404 or Office Of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.

Authority: 5 U.S.C. 301; 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7305, 7313, 7314, 7316, 7317, 7319, 7502, 7701, 8701, 8703, 9102; 46 C.F.R. 12.02; 49

C.F.R. 1.45, 1.46

Purpose: The principal purpose for which this information will be used is to determine domestic and international qualifications for the issuance of merchant

mariner credentials. This includes establishing eligibility of a merchant mariner's credential, duplicate credentials, or additional endorsements issued by the

Coast Guard and establishing and maintaining continuous records of the person's documentation transactions.

Routine Uses: The information will be used by authorized Coast Guard personnel with a need to know the information to determine whether an applicant is a

safe and suitable person who is capable of performing the duties of the Merchant Mariner. The information will not be shared outside of DHS except in

accordance with the provisions of DHS/USCG-030 Merchant Seamen's Records System of Records, 74 FR 30308 (June 25, 2009).

Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may result in non-issuance of

the requested credential.

PRIVACY ACT STATEMENT




Section IV: Mariner's Consent/Certification (continued)

Date (MM/DD/YYYY)Signature of Applicant

x

6. Applicant's Signature

Date (MM/DD/YYYY)Signature of an individual authorized to administer the Oath

x

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DOT/USCG PERIODIC DRUG TESTING FORM

INSTRUCTIONS: This form MAY be used to satisfy the requirements for “Periodic Drug Testing” in accordance with Title 46 CFR 16.220. If you participate in a

USCG “random or pre-employment drug test program,” this form may not be necessary. (See page 2 for details.)

NOTE: The cost of the drug test is the sole responsibility of the applicant, not the Coast Guard.

Name Last First Middle Reference Number (if applicable) Social Security Number

Section I: Applicant Consent

Name Street Address City Zip Code

FOR POSITIVE/ADULTERATED/CANCELLED DRUG TESTS ONLY: (To be reported to the nearest USCG Marine Safety Office). (Please print)

I certify that I meet qualifications for a Medical Review Officer as outlined in Title 49 CFR 40.121. I have reviewed the results and determined that the applicant's

verified test result is in accordance with Title 49 CFR 40 Subpart G.

I certify that I am the described applicant and that I have provided the specimen(s) described below in accordance with Department of Transportation procedures

given in 49 CFR 40. I also understand that making in any way, a false or fraudulent statement, entry, or evidence is a violation of the U.S. Criminal Code at Title

18 U.S.C. 1001 which subjects the violator to federal prosecution and possible incarceration, fine, or both.

Signature of Applicant

xDate (MM/DD/YYYY)

Section II: Name of SAMHSA Accredited Laboratory

State

SECTION III: Medical Review Officer

Date Specimen Collected (MM/DD/YYYY)

Specimen Analyzed For (DOT 5 Panel)

• Marijuana metabolite

• Cocaine metabolites

• Opiates metabolites

• Phencyclidine

• Amphetamines

The laboratory report has been reviewed in accordance with procedures given in 49 CFR Part

40, Subpart G, and the verified test results are: (CHECK ONE)

(Please complete the next block for all non-negative results)

INVALID TEST (Test Cancelled)

POSITIVE/SUBSTITUTED/ADULTERATED or

NEGATIVE

This specimen is verified POSITIVE for

This specimen was identified as being SUBSTITUTED or containing the ADULTERANT

The test was CANCELLED because (insert reason)

MEDICAL REVIEW OFFICER CONTACT INFORMATION MEDICAL REVIEW OFFICER AUTHORITY

Name Last

Street Address

MiddleFirst Name Last First Middle

Signature (MRO signature stamp is authorized for negative results only)

Zip CodeStateCity Name of MRO Qualifying Organization

Registration Number Issued

by Qualifying Organization:Phone:

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CG-719P (01/14) Page 2 of 2

DOT/USCG PERIODIC DRUG TESTING FORM



C.F.R. 1.45, 1.46







Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may result in non-issuance of

the requested credential.


The United States Coast Guard estimates that the average burden for this report is 5 minutes. You may submit any comments concerning the accuracy of this

burden estimate or any suggestions for reducing the burden to: Commanding Officer, U. S. Coast Guard National Maritime Center, 100 Forbes Drive,

Martinsburg, WV 25404 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.

REQUIREMENTS

• A drug test is required for all transactions EXCEPT endorsements, documents of

continuity, duplicates, and STCW certificates.

• Only a DOT 5 Panel (SAMHSA 5 Panel, formerly NIDA 5), testing for Marijuana,

Cocaine, Opiates, Phencyclidine, and Amphetamines will be accepted.

OPTION I

PERIODIC TESTING PROGRAM

• A USCG drug test conducted within the past 185 days by a laboratory accredited by

Substance Abuse and Mental Health Services Administration (SAMHSA), Department

of Health and Human Services.

• COLLECTION of a urine sample may be conducted by an independent medical

facility, private physician or at an employer-designated site as long as the collection

agent meets the qualification requirements to be a collection agent given in Title 49

CFR Part 40.30. It is CRITICAL that the sample is sent to an accredited SAMHSA

laboratory for ANALYSIS or the drug test is invalid.

• The ORIGINAL results are required. A FACSIMILE is acceptable, if it is originated

from the Medical Review Officer (MRO) or the Service Agent assisting the mariner,

and sent directly from the office. The drug test result must be signed and dated by the

MRO or by a representative of the service agent who assisted you in meeting this

requirement.

OPTION II

RANDOM TESTING

EXAMPLE (From Mariner Employers): APPLICANT'S NAME/SSN has been subject to a

random testing program meeting the criteria of Title 46 CFR 16.230 for at least 60 days

during the previous 185 days and has not failed nor refused to participate in a chemical

test for dangerous drugs.

EXAMPLE (Active Duty Military/Military Sealift Command/N.O.A.A/Army Corps of

Engineers): APPLICANT'S NAME/SSN has been subject to a random testing program

with no subsequent positive drug test results during the remainder of the six month period.

OPTION III

PRE-EMPLOYMENT TESTING

• An ORIGINAL DATED letter on mariner employer stationary signed by a company

official, stating that you have passed a pre-employment chemical test for dangerous

drugs within the past 185 days.

EXAMPLE: APPLICANT'S NAME/SSN passed a chemical test for dangerous drugs,

required under Title 46 CFR 16.210 within the previous six months of the date of this letter

with no subsequent positive drug test results during the remainder of the six month period.

Reset

CG-719K/E (01/14) Page 1 of 4



APPLICATION FOR MERCHANT MARINER MEDICAL CERTIFICATE FOR ENTRY LEVEL RATINGS

------ Instructions ------

Who must submit this form?

Entry level rating applicants seeking a Medical Certificate are required to complete this form and submit it to the U.S. Coast Guard. Guidance for required

submission of this form can be found at the National Maritime Center website (http://www.uscg.mil/nmc/medical/default.asp).

Section I: Applicant Information - To be completed by the Applicant

• Legal Name - Enter complete legal name.

• Reference Number - If you have been credentialed by the Coast Guard in the past, enter your reference number.

• Date of Birth - If applicant is under 18 years of age, notarized statement from legal guardian is required. Attach a notarized statement, signed by a parent or

guardian, authorizing the Coast Guard to issue a Medical Certificate.

• Gender - Enter your legal gender.

• Home Address - Principle place of residence. PO Box is not acceptable.

• Delivery/Mailing Address - The address to which you want all correspondence and issued certificates sent. If blank, correspondence and credentials will be

sent to the Home Address.

• Primary Phone Number - Provide a primary phone number.

• Alternate Phone Number - Provide an alternate phone number (optional).

• E-mail Address - The National Maritime Center (NMC) may attempt to contact you via e-mail. You will receive automated updates regarding the status of

your application (optional).

• Other - Please provide additional means of communicating with you (satellite phone, work phone, etc.) (optional).

Section II: Applicant Certification - To be completed by the Applicant

Self-explanatory

Section III: Physical Information - To be completed by the Medical Practitioner

Remove Instructions before submitting Application

Self-explanatory

Section IV: Demonstration of Physical Ability - To be completed by the Medical Practitioner

Title 46 of the Code of Federal Regulations (CFR) requires that ratings, including entry level, and food handler serving on vessels to which STCW applies

must provide a demonstration of physical ability. The following is a list of activities the applicant shall be physically able to perform: For a vessel to be

operated safely, it is essential that the crewmembers be physically fit and free of debilitating illness and injury. The seafaring life is arduous, often hazardous

and the availability of medical assistance or treatment is generally minimal. As the international trend toward smaller crews continues, the ability of each

crewmember to perform his or her routine duties and respond to emergencies becomes even more critical. All mariners should be capable of living and

working in cramped spaces, frequently in adverse weather causing violent evolutions such as firefighting or launching lifeboats or life rafts. Members of the

deck and engine department must be capable of physical labor, climbing, and handling moderate weights (from 30-60 pounds). Detailed guidance on the

medical and physical evaluation guidelines for merchant mariner credentials is contained in Navigation and Vessel Inspection Circular (NVIC) 04-08.

Additional information is also available at the National Maritime Center (NMC) website at: http://www.uscg.mil/nmc/medical.asp. Additional information can

also be obtained from NMC at: Commanding Officer, National Maritime Center, 100 Forbes Drive, Martinsburg, WV 25404, 1-888-IASKNMC

(1-888-427-5662).

CG-719K/E (01/14) Page 2 of 4

Section IV: Demonstration of Physical Ability - (continued)

LISTS OF TASKS CONSIDERED NECESSARY FOR PERFORMING ORDINARY AND EMERGENCY RESPONSE SHIPBOARD FUNCTIONS

Shipboard Tasks, Function,

Event, or ConditionRelated Physical Ability Acceptable Demonstration

Routine movement on slippery,

uneven, and unstable surfacesMaintain balance (equilibrium) Has no disturbance in sense of balance

Routine access between levels Climb up and down vertical ladders and stairwaysIs able, without assistance, to climb up and down vertical

ladders and stairways

Routine movement between

spaces and compartments

Step over high doorsills and coamings, and move

through restricted accesses

Is able, without assistance, to step over a doorsill or

coaming of 24 inches (600 millimeters) in height. Able to

move through a restricted opening of 24 x 24 inches

Open and close watertight doors,

hand cranking systems, open/

close valve

Manipulate mechanical devices using manual and

digital dexterity, and strength

Is able, without assistance, to open and close watertight

doors that may weigh up to 55 pounds (25 kilograms);

should be able to move hands/arms to open and close

valve wheels in vertical and horizontal directions; rotate

wrists to turn handles; able to reach above shoulder

height

Handle ship's stores Lift, pull, push, carry a load

Is able, without assistance, to lift at least a 40 pound (18.1

kilograms) load off the ground, and to carry, push, or pull

the same load

General vessel maintenance

Crouch (lowering height by bending knees); kneel

(placing knees on ground); stoop (lowering height by

bending at the waist); use hand tools such as spanners,

valve wrenches, hammers, screwdrivers, pliers

Is able, without assistance, to grasp, lift, and manipulate

various common shipboard tools

Emergency response procedures

including escape from smoke-filled

spaces

Crawl (ability to move body using hands and knees);

feel (ability to handle or touch to examine or determine

differences in texture and temperature)

Is able, without assistance, to crouch, kneel, and crawl,

and to distinguish differences in texture and temperature

by feel

Stand a routine watch Stand a routine watchIs able, without assistance, to intermittently stand on feet

for up to four hours with minimal rest periods

React to visual alarms and

instructions, emergency response

procedures

Distinguish an object or shape at a certain distance

React to audible alarms and

instructions, emergency response

procedures

Hear a specified decibel (dB) sound at a specified

frequency

Make verbal reports or call

attention to suspicious or

emergency conditions

Describe immediate surroundings and activities, and

pronounce words clearlyIs capable of normal conversation

Participate in fire fighting activitiesBe able to carry and handle fire hoses and fire

extinguishers

Is able, without assistance, to pull an uncharged 1.5 inch

diameter, 50' fire hose with nozzle to full extension, and to

lift a charged 1.5 inch diameter fire hose to fire fighting

position

Abandon ship Use survival equipment

Has the agility, strength, and range of motion to put on a

personal flotation device and exposure suit without

assistance from another individual

Section V: Food Handler Certification - To be completed by the Medical Practitioner

The Medical Practitioner shall complete this section for all applicants requiring Food Handler Certification. The Medical Practitioner need not perform any

additional laboratory testing unless it is deemed clinically necessary. Applicants and currently employed food workers should report information about their

health as it relates to diseases that are transmissible through food. The following issues should be considered by the Medical Practitioner when certifying an

applicant:

a. The applicant reports they have been diagnosed with an illness due to organisms such as Salmonella Typhi, Shigella spp., Shiga-toxin-producing

Escherichia coli, Hepatitis A virus, etc.

b. The applicant reports they have at least one symptom caused by illness, infection, or other source that is associated with an acute gastrointestinal illness

such as diarrhea, fever, vomiting, jaundice, or sore throat with fever.

c. The applicant reports they have a lesion containing pus, such as a boil or infected wound, which is open or draining and is on hands or wrists or on

exposed portions of the arms.

d. The applicant reports they have had Salmonella Typhi within the past three months, Shigella spp. within the past month, Shiga toxin producing Escherichia

coli within the past month, or Hepatitis A virus ever.

e. The applicant reports they are suspected of causing or being exposed to a confirmed disease outbreak caused by organisms such as Salmonella Typhi,

Shigella spp., Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc. This would include outbreaks associated with events such as a family meal,

church supper, or festival because the employee ate food implicated in the outbreak, or ate food at the event prepared by a person who is infected or who

is suspected of being a shedder of the infectious agent.

f. The applicant reports they live in the same household as, and have knowledge about, a person who is diagnosed with organisms such as Salmonella

Typhi, Shigella spp., Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc.

g. The applicant reports they live in the same household as, and have knowledge about, a person who attends or works in a setting where there is a

confirmed disease outbreak caused by organisms such as Salmonella Typhi, Shigella spp., Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc.

CG-719K/E (01/14) Page 3 of 4



APPLICATION FOR MERCHANT MARINER MEDICAL CERTIFICATE FOR ENTRY LEVEL RATINGS

Section I: Applicant Information - To be completed by the Applicant

Last Name First Name Middle Name Suffix (Jr., Sr., III)

Reference Number (if applicable) Gender: Date of Birth (MM/DD/YYYY)

Section II: Applicant Certification - To be completed by the Applicant .

Please indicate best method(s) of contact by checking the appropriate box(es). Optional if information is same as most recent CG-719B.

My signature below attests, subject to prosecution under 18 USC 1001, that all information provided by me on this form is complete and true to the best of my

knowledge. I have also read and understand the Privacy Act Statement that accompanies this form.

Body Mass Index (BMI)Weight (lbs)Height (Inches Only)

Distinguishing Marks: (Please Print)

Section IV: Demonstration of Physical Ability - To be completed by the Medical Practitioner .

An applicant for an Entry Level Rating [ordinary seaman, wiper, or steward's department (food handler)] serving on vessels to which STCW applies is not

required to complete a physical examination, but must provide a demonstration of physical ability as described in Section IV of the Instructions.

Signature of Applicant Date (MM/DD/YYYY)

Zip CodeStateCity

Street Address

Home Address (PO Box NOT acceptable)

Delivery/Mailing Address, if different (PO Box acceptable)

Zip CodeStateCity

Primary Phone Number

Alternate Phone Number

E-mail Address

Other

Section III: Physical Information - To be completed by the Medical Practitioner

Place an X in the appropriate block below:

Applicant does NOT have the physical strength, agility, and

flexibility to perform all of the items in the instruction table.

Applicant has the physical strength, agility, and flexibility to

perform all of the items in the instruction table.

Comments (Please Print)

Section V: Food Handler Certification - To be completed by the Medical Practitioner .

If Food Handler Certificate is sought by the applicant, is applicant free from

communicable disease:NoYes

FemaleMale

CG-719K/E (01/14) Page 4 of 4

Medical Practitioner: This signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by the medical practitioner is true and correct to the

best of his/her knowledge and that the medical practitioner has not knowingly omitted or falsified any material information relevant to this form.

Zip CodeStateCity

Street Address

M.I.First NameLast Name

Date (MM/DD/YYYY)Signature

MD/DO PA NP

Phone Number:

License Number State

(Place office address stamp here)


The United States Coast Guard estimates that the average burden for this form is 10 minutes. You may submit any comments concerning the accuracy of this

burden or any suggestions for reducing the burden to the National Maritime Center, 100 Forbes Drive, Martinsburg, WV 25404.


C.F.R. 1.45, 1.46







Disclosure: Furnishing this information is voluntary; however, failure to furnish the requested information may result in non-issuance of the requested

credential.


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